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A Revision of Expectations

Richard Horton

The National Health Service: A Political History by Charles Webster
Oxford, 233 pp, £9.99, April 1998, ISBN 0 19 289296 7

On the evening of 10 March 1969, Richard Crossman, Harold Wilson’s new Secretary of State for Social Services (‘SSSS? Impossible!’ Crossman wrote in his diary), reached into one of his three ministerial red boxes to find a long report by a still rather obscure Conservative barrister. Geoffrey Howe had entered Parliament in 1964, only to lose his seat when Wilson increased Labour’s majority from four to 95 in 1966. Crossman’s predecessor, Kenneth Robinson, had appointed Howe to chair an inquiry into scandalous allegations, made in the News of thr World, of cruelty, torture and theft at Ely Hospital, a psychiatric institution near Cardiff. Howe’s final report had been submitted in September 1968, a month before Crossman took up his new portfolio. The Ministry had by then spent six months arguing that Howe’s explosive eighty thousand words should remain confidential; only a brief summary would be published. ‘Not on your life,’ Howe had said, according to Crossman’s diary. Eventually, with three drafts – complete, slightly curtailed and concise – in his red box, Crossman had two days to approve publication of the concise version.

His instinct was to overrule the more cautious officials and publish the complete report. If he didn’t, ‘Geoffrey Howe would be entitled to go on television and talk about suppression.’ That night he read the appalling details about Ely from cover to cover. The original newspaper story was ‘completely substantiated’. Patients had been ill-treated; ward staff had stolen their food; there was overcrowding and a shortage of properly trained staff; patients and doctors felt isolated and abandoned; and nurses believed they would lose their jobs if they complained. Crossman realised that publication of these findings on their own would be perilous: he had to devise a policy to meet Howe’s criticisms.

Two days later, Crossman had persuaded his officials to take some responsibility for what had gone on at Ely. In 1969, 250,000 people were suffering long-stay hospital care similar to that offered at Ely, ‘cooped up in these old public assistance buildings with no adequate inspectorate’. Crossman’s civil servants opposed outright his plan for an inspectorate: there would be no way of making it work, doctors were likely to reject it and, anyway, there was too little time to make proper arrangements. But if there was still a case for suppressing Howe’s investigation, it collapsed when Crossman discovered that his Ministry had known about the goings-on at Ely for at least three years. Crossman acted swiftly. He won approval for an independent inspectorate that would report directly to him, and received consent to make a statement in the Commons on 27 March. He told full Cabinet on 25 March.

Wilson was furious. Crossman (and, indeed, the Leader of the House) had forgotten that three by-elections were due to take place on the day of the Ely statement. Wilson ‘wondered how it was possible that one should ruin the chances of people voting Labour by having this terrible story blurted out on the six o’clock news’. Crossman began his speech to Parliament with a ‘great frog’ in his throat. He knew immediately he ‘had gripped the House by admitting the truth of the allegations, the excellence of the report and the need for remedial action’. He also spoke about the possibility of appointing a Health Commissioner, or Ombudsman, to investigate complaints about the NHS. But Wilson’s political judgment had been sound: the Conservatives won all three by-elections, with large swings in each case.

Crossman’s achievement was to begin a systematic review of the health services – of the care of the mentally ill, especially – a process unheard of in the NHS since its inception in 1948. In a gratifyingly compressed, although at times grey, account, Charles Webster concludes that the Ely episode brought ‘a fresh spirit of determination’ to the care of long-stay patients. It did more than that: it released additional money, spurred improvements in hospital facilities and raised standards of practice. Ministers at last had a mandate to tackle the organisation and funding of the Service. Crossman’s collaboration with Howe was an agreeable moment of bipartisanship: in the 50-year history of the NHS, there hasn’t been another like it.

William Beveridge’s 300-page report, Social Insurance and Allied Service, was submitted in November 1942. By the end of 1944, it had sold over 200,000 copies. It had been commissioned with postwar reconstruction in mind and was to lead to one of this country’s most underplayed political successes. ‘Assumption B’ set out, in only a few thousand words, a compelling and extraordinary vision. (‘Assumption A’ was a ‘general scheme of children’s allowances’.) What Beveridge proposed was ‘a health service providing full preventive and curative treatment of every kind to every citizen without exceptions, without remuneration limit and without an economic barrier at any point to delay recourse to it’. It was, he concluded, ‘the ideal plan ... to reduce the number of cases for which [social security] benefit is needed’. Judged by this particular measure, Beveridge’s ideal plan has failed. But the NHS is Assumption B’s remarkable monument.

Beveridge was an unlikely hero of the poor. He was born in 1879 in India, the son of a judge who had 26 servants. After he left Oxford, where he read mathematics and classics, he took up research among the poor in London’s East End. He knew Beatrice Webb, who, in 1909, was the first person to put the case for a free state medical service available to all. Some saw him as a kind and humane public servant; others as a vain, mean-spirited bureaucrat. He could be very odd, and once tried to convince Wilson that cycles of unemployment were linked to sun-spot activity.

Although the Second World War brought together a chaotic and haphazard hospital system, the NHS was not the straightforward product of a wartime crisis. Events in the preceding century had made the political argument for some kind of national health system irresistible. Edwin Chadwick, as secretary of the Poor Law Commission, had been the guiding force in drawing up a strategy. His 1842 report led to Britain’s first Public Health Act in 1848. This revolutionary document tried to counter the effects of industrialisation by providing powers to construct decent water supply and sewerage systems, which in turn led to an important decline in infectious diseases such as cholera and typhoid.

That milestone was followed by the Royal Sanitary Commission of 1869-71, and two further Public Health Acts in 1872 and 1875, as a result of which newly appointed Medical Officers of Health were charged with raising standards of community health, preventing infectious disease and combating illnesses arising out of poverty. The Boer War was a further jolt to those anxious about the nation’s health. The dismal physical state of army recruits threatened the war effort and led to recommendations for improving child health, together with the introduction of school meals and medical services. The 1902 Midwives Act professionalised midwifery; the 1907 Notification of Births Act established health visiting as a service provided by local authorities; the 1918 Maternity and Child Welfare Act added further improvements to mother and infant medicine. This abundance of legislation led finally to the creation of a much-needed Ministry of Health in 1919. Free general practitioner services, available to working people earning less than £160 per year, had already been provided under the 1911 National Insurance Act. GPs, fearing state control of their practices and therefore bitterly opposed to Lloyd George’s plans, were bought off by generous payments, based on the number of patients on their lists. The new service flourished. By 1945, two-thirds of GPs and 21 million people (half the population) had signed up to this scheme.

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Letters

In his piece on the history of the National Health Service and its imminent prospects (LRB, 2 July), Richard Horton tells us that ‘a dramatic improvement in the standards of hospital and high-technology medicine to match those found, for example, in the US could be achieved easily only by discarding the principles of universal, comprehensive and free health care.’ This zero-sum game approach to healthcare is all too typical when the problems of the NHS come up for discussion, and it’s high time it was abandoned. The fact that many Americans can get very advanced medical treatment when they need it, and the fact that 40 million other, poorer Americans don’t have health insurance, and will get either inferior or no treatment, are not connected by economic logic: they are connected by a failure of political will and by an apparent withering of the social conscience that should be arguing for reform. Setting the terms of debate in this country in the stark terms favoured by Horton, as if the high-technological and the free and universal were inevitably opposed, and as if no middle way were feasible between them, is the opposite of helpful. We should simply be asking that the divide between the best care available and the worst be made as narrow as possible, and that if we’re going to compare standards of treatment we do so between different parts of one country, not between this country and others.

Richard Horton’s article on the National Health Service (LRB, 2 July) did not mention Canada’s successful health provision, Medicare. Last May I was stricken with life-threatening brain damage. I spent five months in hospital, in intensive care some of the time. In the first of three hospitals in which I received treatment, after a certain number of days I paid a minimal charge of $777 per month. In the second hospital there was no charge. In the third – a walk-in clinic to which I shall return for therapy – I paid for one meal and transport (in the US, one pays $1700 per day, plus, of course, charges for x-rays, scans etc).

A recent poll indicated that 97 per cent of Canadians are prepared to pay higher taxes to maintain the present standard of health services. In addition, the Federal Government in Ottawa has promised to spend millions of dollars more on Medicare after the next election. Nevertheless, we face some of the same problems mentioned by Horton, one of which is the increasing age of the population (I am 82). Ways of coping with these problems include cutting administration costs; recognition that patients with serious illnesses which are not life-threatening must wait until beds are free; meals on wheels; and local walk-in clinics with trained staff. The latter are located all around the city of Montreal; they are easily accessible for parents who bring their children for minor complaints and are less intimidating than large hospitals.